Overview
Definition:
Facial lacerations in children are common injuries requiring prompt and appropriate management
Distinguishing between simple and complex lacerations is crucial for optimal cosmetic and functional outcomes
Simple lacerations involve the superficial layers of the skin and subcutaneous tissue, while complex lacerations may involve deeper structures like nerves, vessels, muscles, or extend through the full thickness of the lip or eyelid, or be associated with significant contamination or tissue loss.
Epidemiology:
Facial injuries are a frequent reason for pediatric emergency department visits, with lacerations accounting for a significant proportion
Falls, playground accidents, sports-related injuries, and motor vehicle accidents are common etiologies
Boys tend to have higher incidence rates than girls, especially in younger age groups
The location and severity vary widely based on the mechanism of injury and the child's activity level.
Clinical Significance:
Proper management of facial lacerations in children is paramount due to the aesthetic and functional importance of the face
Inadequate repair can lead to visible scarring, asymmetry, functional deficits (e.g., ectropion, trichiasis, impaired eyelid closure), and psychological distress
Early and precise wound assessment, appropriate cleansing, and meticulous repair techniques are essential for minimizing long-term morbidity and optimizing patient outcomes.
Clinical Presentation
Symptoms:
Chief complaint of a visible cut or wound on the face
Pain and discomfort at the site of injury
Parents or caregivers may report the mechanism of injury, such as a fall, impact, or sharp object exposure
Bleeding from the wound
Possible impairment of facial movement or vision depending on the location and depth.
Signs:
Visible discontinuity in the skin
Depth of the wound can range from superficial epidermal abrasion to full-thickness defects
Presence of foreign bodies within the wound
Bleeding, ranging from capillary oozing to pulsatile arterial hemorrhage
Edema and ecchymosis around the laceration
Loss of normal tissue landmarks
Potential nerve involvement (e.g., facial nerve deficit), vascular compromise, or involvement of special anatomical areas like the eyelid, lip, or brow.
Diagnostic Criteria:
There are no formal diagnostic criteria for lacerations
diagnosis is primarily clinical based on visual inspection of the wound and elicitation of the injury history
Classification into "simple" vs
"complex" is based on wound characteristics: depth, length, complexity of edges, involvement of underlying structures, contamination level, and anatomical location.
Diagnostic Approach
History Taking:
Detailed history of the injury mechanism (e.g., fall, animal bite, sharp object, sports injury)
Time of injury
Status of tetanus immunization
Any known allergies, particularly to antibiotics or anesthetics
History of bleeding disorders or medications affecting coagulation
Assessment of the child's overall health status
Red flags: suspected head injury, loss of consciousness, significant bleeding, suspected fracture, or injury to critical structures like the eye.
Physical Examination:
Thorough assessment of the facial wound, including length, depth, width, and orientation
Palpation for crepitus (suggesting underlying fracture) or foreign bodies
Examination for involvement of underlying structures: muscles (e.g., orbicularis oculi function), nerves (e.g., facial nerve branches), cartilage (e.g., ear), bone, and mucous membranes
Assess for signs of infection (erythema, warmth, purulent discharge)
A detailed ophthalmic examination is mandatory for periorbital or eyelid lacerations
Assess for range of motion and symmetry of facial expressions.
Investigations:
Generally, investigations are not required for simple lacerations
For complex lacerations, consider: X-rays if underlying fracture is suspected
CT scan if significant facial trauma or suspicion of intracranial injury
Ultrasound may be useful for detecting retained foreign bodies in superficial tissues
Wound cultures if signs of infection are present or high suspicion of contamination (e.g., animal bites).
Differential Diagnosis:
Abrasions, avulsions, contusions, bites (human or animal), crush injuries, punctures
It is crucial to differentiate lacerations from these other types of soft tissue trauma, as management strategies may differ.
Management
Initial Management:
Assess and secure the airway, breathing, and circulation (ABCs)
Control hemorrhage with direct pressure
Assess the need for pain management and sedation, especially in young children
Thorough wound irrigation with sterile saline or water to remove gross contamination and debris
Administer tetanus prophylaxis if indicated based on immunization status and wound characteristics.
Medical Management:
Antibiotic prophylaxis is generally not recommended for clean, simple lacerations in immunocompetent children
However, antibiotics are indicated for contaminated wounds, bites (animal or human), and lacerations involving specific anatomical areas like the ear or those with significant tissue devitalization
Common choices include amoxicillin-clavulanate for bites, or cephalexin/erythromycin for superficial skin infections
Topical antibiotic ointments can be applied after repair to promote healing and reduce infection risk.
Surgical Management:
Simple lacerations: require only thorough cleansing and closure, often with absorbable sutures subcutaneously and non-absorbable sutures or adhesive strips for the skin, or simply with adhesive strips for very superficial wounds
Complex lacerations: may require exploration to identify and repair deeper structures (muscles, nerves, vessels)
Techniques include: layered closure with absorbable sutures for deep tissues (fascia, subcutaneous fat) and appropriate sutures for skin (monofilament nylon, polypropylene for cosmetic areas)
Special considerations for lip repair (vermilion border alignment), eyelid repair (vertical mattress sutures for tarsal plate), and eyebrow lacerations (alignment of hair follicles)
Tension-reducing techniques may be necessary for larger or more complex defects
Local anesthesia with lidocaine (with or without epinephrine, depending on location and risk of compromised circulation) is usually sufficient
Sedation or general anesthesia may be required for extensive injuries, uncooperative children, or when precise repair is critical.
Supportive Care:
Pain management with oral analgesics (acetaminophen, ibuprofen) as needed
Cold compresses to reduce swelling and pain
Wound care instructions: keep clean and dry, avoid sun exposure
Monitoring for signs of infection (increasing redness, swelling, pain, fever, purulent discharge)
Follow-up appointment for suture removal (typically 3-5 days for face) and wound assessment.
Complications
Early Complications:
Infection: redness, warmth, swelling, purulent discharge, fever
Hematoma formation
Delayed wound healing
Nerve injury: transient or permanent weakness or sensory deficit
Damage to deeper structures if not identified during initial repair.
Late Complications:
Scarring: hypertrophic scars, keloids, wide scars, or disfiguring scars
Contractures
Residual functional deficits (e.g., ectropion, strabismus)
Cosmetic asymmetry
Chronic pain or dysesthesia.
Prevention Strategies:
Meticulous wound cleansing and irrigation
Appropriate antibiotic use for high-risk wounds
Accurate anatomical and structural assessment
Precise and layered wound closure techniques
Avoidance of excessive tension on wound edges
Proper postoperative wound care instructions to parents
Prompt recognition and management of early complications.
Prognosis
Factors Affecting Prognosis:
Nature of the laceration (depth, contamination, involvement of vital structures)
Timeliness and adequacy of initial management
Skill of the healthcare provider performing the repair
Patient's age and health status
Adherence to postoperative care instructions
Presence of underlying medical conditions.
Outcomes:
Most simple facial lacerations in children heal with minimal to no scarring if managed appropriately
Complex lacerations require skilled reconstruction, and outcomes can vary
Early and expert intervention significantly improves the likelihood of excellent cosmetic and functional results
Reconstructive surgery or scar revision may be necessary for suboptimal outcomes.
Follow Up:
Follow-up appointments are typically scheduled within 3-7 days for wound assessment and suture removal
Longer-term follow-up may be necessary for complex repairs, significant scarring, or functional deficits
Parents should be advised to seek immediate medical attention if signs of infection or wound breakdown occur.
Key Points
Exam Focus:
The distinction between simple and complex facial lacerations is a frequent exam topic
Key areas to focus on include: indications for antibiotics and tetanus prophylaxis, management of specific anatomical areas (lips, eyelids, eyebrows), identification of nerve/vessel injury, and principles of layered closure
Differentiate management of animal vs
human bites
Understand local anesthetic administration in children.
Clinical Pearls:
Always consider the mechanism of injury – it guides suspicion for associated trauma
Meticulous wound edge debridement is crucial
For lip repairs, align the vermilion border precisely
it's a key aesthetic landmark
Eyebrow lacerations require careful closure to allow hair follicle regeneration
For eyelid lacerations, ensure the integrity of the tarsal plate and canalicular system
Use fine sutures for excellent cosmetic results on the face
Involve a plastic surgery or ENT consult for complex facial trauma or when expertise is lacking.
Common Mistakes:
Failure to adequately irrigate the wound, leading to increased infection risk
Inadequate assessment for underlying structural damage (nerves, muscles)
Improper alignment of facial landmarks, especially the vermilion border or eyebrow
Overlooking the need for tetanus prophylaxis or antibiotics in contaminated wounds
Inappropriate use of epinephrine-containing local anesthetics in critical areas
Delaying referral for complex cases requiring specialist management.